The Acute Pain Service Nurse Practitioner: A Case Study in the Postoperative Care of the Child With Bladder Exstrophy

Lori J.Kozlowski, MS, RN, CPNP


J Pediatr Health Care. 2008;22(6):351-359. 

In This Article

The Pediatric Pain Service

At the Johns Hopkins Children's Center, a Pediatric Pain Service is intimately involved in the care of children with bladder exstrophy, providing state-of-the-art pain control in an attempt to improve patient comfort and surgical success. Specific programs for pain management can take several forms, depending on the type and number of patients treated, resources available, and economic limitations. Many programs are organized and led by anesthesiologists, but alternative models vary from large multidisciplinary teams to small consulting services involving nurses, physicians, and pharmacists. Gordon, Pellino, Enloe, and Foley (2000) describe a nurse-run inpatient pain consultation service as a strategy to improve the quality of pain management in an academic tertiary care hospital. Regardless of the model, the benefits of a hospital pain management team have been widely recognized. Their activity and dissemination of knowledge leads to increased patient satisfaction, decreased pain intensity, and a decrease in opioid adverse effects (Musclow, 2005). At the Children's Center, a PNP-based, anesthesiologist-supervised acute pain service model is used. The service structure is based on a core group of attending pediatric anesthesiologists with an interest in pain management and four PNPs. This team takes responsibility for the development of standards for pain assessment and management and provides hands-on 24-hour, 7-days-per-week coverage. This group of nurse practitioners and physicians has pain management as their primary daily task and are available by consultation to the entire Children's Center. The anesthesiologists' expertise in pain management places them in an ideal position to bring leadership to the Pain Service and provides an important link between colleagues. The NPs are in an ideal role to provide leadership in both the organization and delivery of enhanced pain management services. Their role includes provision of services, education, policy and procedure development, and research.

The Pediatric Pain Service at Johns Hopkins Children's Center treats approximately 1500 patients per year, with an average daily census of 20 to 40 patients. The anesthesiologists spend a portion of their day making rounds with the NP in the Pain Service. They may also be involved in anesthesia/sedation services at other locations. The NP makes daily rounds for all patients monitored by the Service. Rounds encompass 65% to 85% of the day, depending on the caseload. Because NPs have prescriptive authority in Maryland, they can initiate analgesia, allowing for prompt management of pain. Other aspects of daily rounds involve supervision of analgesia, monitoring of pain scores, troubleshooting technical problems, providing support to the primary nurse, providing ongoing education to patients, families, and other health care professionals, and consultation with the anesthesiologist for problematic patients. The Pediatric Pain Service is recognized and respected for the services provided. The Service is a source of clinical research and sets standards for practice locally, nationally, and internationally.

Information management is provided by a database compatible with the hospital's computer network, which allows generation of orders and clinical note writing. A notebook provides a sign-out list that includes the following information about patients: name, age, weight, diagnoses, history, location, and types of analgesics used. This information is forwarded to the billing department for reimbursement purposes. A relational database to track outcomes, complications, sentinel events, and clinical volumes is in development.

To fully appreciate the complexity of care of children with bladder exstrophy and ultimately the role of the NP, an overview of the exstrophy condition will be presented.


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